Memory

I recently read an interesting blog post over on Thought Broadcast titled “Google Is My New Hippocampus.” Aside from the fact that I find that title absolutely hilarious*, it’s a great post about the ways that we remember information in the age of the search engine, and it asks some interesting questions about how medical students learn when everything can be googled.

My version of the google-hippocampus connection is the sentence, “I’m not sure, but the internets know.” This is my response to a wide variety of questions on everything from pop-culture to history to science, and everything in between. (Recent examples include: How many times has Gene Simmons been married? Do seagulls hunt other animals or are they just scavengers? What was the name of that blond guy in the first Final Destination movie? How old was our “founding father” John Quincy Adams at the time of the Declaration of Independence?”) To be fair, if he is present, I am more likely to ask my husband these questions before I result to internet searching. For reasons I do not understand, he is often at least as annoyed by my truly random inquiries as he is flattered by my assumption that he knows, quite literally, everything.

Now some of the things that I google I really should know already, but as those examples suggest, a lot of my googling is the result of random curiosity about things that should not necessarily be taking up space in my brain. I think that illustrates a real difference in approach between people in my generation and folks in the generations before: I expect that the information I need will always be rapidly accessible. This does not apply only to the randomness, but also to the important stuff. Uptodate will tell me in seconds what the first-line antibiotic for a specific infection is, PubMed will happily guide me to efficient little summaries of a wealth of literature about any area of medical science that strikes my fancy, and I can download the full text with a click. If I don’t know already, I know I can find out, as long as I can come up with the right search terms. And I admit that when I can’t find something almost instantaneously, I become very annoyed.

Before I go on, allow me to say that in general, I think rote memorization is the lowliest, basest, and most pointless form of learning. I do not say this just because I am not particularly good at it, although I admit that I find it hopelessly boring. And I do not base this on the fact that google will tell me things that I don’t have stored up. I honestly think that 90% of memorization is a waste of time that would be better spent analyzing and manipulating the information to be memorized with access to a reference book. For example, I don’t feel like I necessarily “learned” anything by spending an afternoon first year cultivating the ability to recite the urea cycle. However, I absolutely learned something when I sat down with a diagram of it in front of me and rationalized my way through which enzyme deficits would lead to which lab results. On this point, I am decidedly with Einstein, “Never memorize what you can look up.”

That being said, I don’t think that the easy access to whatever information I desire has changed my medical education as much as that post suggests, in part because medical education has changed tragically little since days gone by. My philosophy of trying to understand things without bothering to memorize them does not serve one well in the first year of medical school. Sure, with a true understanding of a concept, you can often rationalize your way to the correct answer on a multiple choice question, but not with 70 seconds/question. And tragically, no matter how I wished for it, there was no google window on my biochemistry exams. Make no mistake about it, even in the information age, preclinical medical students are still forced into hours of hours of rote memorization of volumes of facts (many of which have little or no application to practical human health.)

Therefore, I think that the question we should be asking here is not, “Are medical students somehow learning less now that they don’t have to memorize things?” but rather, “Could medical students be learning MORE if we stopped making them memorize things?” I know that I would understand more of what I learned in biochemistry and anatomy if I had been forced to memorize less of it.

The thought broadcast post makes a case that overall memorization and the selective forgetting of the things that you don’t need yields a more comprehensive understanding of medicine. Here I think that he’s flat out wrong. In fact, I would advocate for the opposite. Time spent memorizing is time that could better be spent actually working with the information, and I think that the latter is more likely to lead to the kind of knowledge and understanding that we want our physicians to have. The bits of information that you actually need usually will be memorized as you use them: no flashcards, drilling, or other torture necessary. For example, there once was a time that I needed to check a periodic table to know the charge on a sodium or calcium ion. I don’t need to do that anymore. This is not because I spent time with flashcards memorizing the charges of ions (or even nerdier, memorizing the periodic table), but because I have used that information enough that it stuck, and now I will never forget it. In contrast, off the top of my head, I don’t know the charge on a manganese ion, but my day to day life has never suffered for that lack.

The sad (and awesome) reality is that medicine has become far too large to be contained in a single human mind. It is impossible to memorize everything that you might need to know to be successful in a single specialty, let alone the little bit of everything that they toss at you in the first two years of medical school. I honestly don’t think it serves us well that medical students spend so much of their time in the first two years blindly memorizing facts and honing their skills at single-best-answer multiple-choice questions. Frankly, that’s not how we’re going to need to use that information in the real world. Patients do not turn up to the ER with little cards attached to their chests offering five possible diagnoses to choose from.




I think that to rely on memorization is to imagine that the information memorized is static and unchanging, a frankly dangerous assumption in the world of modern medicine.

So yes, occasionally I do worry that I didn’t learn enough in the first two years when someone asks me how a medication works, and I have to turn around and ask google for the answer.(The worst question so far, “I have pain here. I think its tendonitis. Which tendon is that and what should I do about it?” Limb anatomy is not my friend.) But overall, I think that having an internet based hippocampus is preferable by far to having a lot of information memorized, but no idea at all how to use it when faced with an actual person.

*For those not up on functional neuroanatomy jokes, the hippocampus is a region of your brain that is essential for long term memory.

The Emotion and Passion of Scientific Language

In the December 2010 issue of JAMA, Robert Brook writes an essay titled "A Physician = Emotion + Passion + Science." In it, he makes the argument that we should use language that more engages the "right brain" in our discussions of science today.

He might be right about that to a certain extent. To be honest, I am a little conflicted on the point. Certainly, it can be hard to communicate exciting ideas in the dry passive voice of modern scientific writing. Perhaps a little panache would help, (although I might stop before putting a cartoon in the middle of a research article in NEJM.) At the same time, I think that there is a purpose to the detached voice of scientific writing. After all, when we publish our findings we are basically putting them out there to face the scrutiny of our colleagues and our community. There is something to be said for a world in which we mostly "let the facts speak for themselves" in this initial presentation, and save our more passionate debates for other venues. A not-so-small part of me that believes that using precise, if dry, language and a specified format in the publication of research results is more than a necessary evil, but a strength of the scientific process. Perhaps we need not to change the presentation of research findings, but create a new venue to allow for the discussion of the work and the debates that an exciting paper can so often precipitate to take place in a more clearly defined public forum. That is, preserve the integrity of the presentation of results, but also provide a venue and a broader audience for the passion and excitement (and disappointment) that those results can provoke. It's certainly something to think about.

But regardless of his point, some of Dr. Brook's reasons for making it are both depressing and downright wrong.

The article contains the following paragraph: "Not very long ago… Each patient was an individual with a family and a community. Each physician was an individual with a small amount of technology at his or her disposal. Every patient required a different art of care, whether it was the way the patient was touched by the physician or the manner in which experiences were shared or questions were asked. Without available or sufficient health insurance, physicians and patients had to work together to produce treatment plans that were consistent with the patients' culture and socioeconomic status and that reflected the patients values about the kind of care that they wanted and did not want."


Anybody out there want to tell me why on Earth that paragraph is in the past tense? Brook's argument is that as technology has improved, care has become increasingly standardized, and that this standardization has led scientific communication becoming "standardized, emotionless and dispassionate." But I think (hope, pray) that this past tense idea of even remotely personalized medicine is downright false. Admittedly, I'm a long way away from being a practicing physician, but I hope that every treatment plan I come up with, for my entire career, is consistent with the patient's culture and reflects the patient's values about the kind of care they want or do not want. Nobody, physician or patient, should find anything less even remotely acceptable. And while it is nice to imagine that in the beautiful modern world of insurance, we no longer have to consider the patient's socioeconomic status, or the cost of treatment options, in reality, not doing so is beyond irresponsible and will only cause both the patient and the system further harm. Dr. Brook's putting a personal doctor-patient relationship into the past tense, dismissing the modern need for custom designed personal care, and awareness of the cost, is something of a tragedy, but I don't think it has anything to do with the dry language of scientific papers. Thankfully, I can't think of a single one of my colleagues that plans to practice this "standardized, emotionless and dispassionate" form of medicine that he seems to think is all we have left.

Dr. Brook goes on to say, "It is difficult to imagine a young physician growing up in this communication environment, trying to focus his or her brain on science studies that seem to be written in a language as foreign as medieval English would be to modern inhabitants of the British Isles." Now, I am currently struggling with the writing of a scientific paper, and I will be the first to admit that the language doesn't always come easily, and that I am writing for a specific audience. I've often told my husband and my mother that they don't have to prove they love me by reading my scientific articles. Still, if they did make an attempt, I assure you that they, all of you, and all of the other "young physicians" I know, would have a far easier time reading "Disrupted reinforcement signaling in the orbitofrontal cortex and caudate in youths with conduct disorder or oppositional defiant disorder and a high level of psychopathic traits" than The Canterbury Tales in the original. I would like to believe that those of us that have chosen the field of medicine don't need a gimmick to focus on the science for a little while, and I hope that most of those that have preceded me into the field will give us a little more credit than Dr. Brook seems willing to.

So yes, perhaps we could enliven medical research with a little more emotion. I'm all for putting the debate and discussion that is the most exciting part of science into a public forum and letting the people that care passionately about a topic teach us all.

I'm even more for making the time in the medical school curriculum to have emotions and passions outside of the raw science that we all must learn, and it seems like that may be where Brook is hurting. It's not the flaws of the dry language of the modern scientific paper that he is telling us about in this essay, but perhaps a deeper feeling of being unable to express his emotions in the modern dialogue of medicine. To be honest, I feel a little sorry for him. At the same time, I'm pretty sure that the answer isn't more emotional imagery in my next paper.

I may be spending a lot of my time with the dry language of science at the moment, but I hope that the emotion and passion that brought me to medicine will help keep my experience from being what Dr. Brook seems to see. This upcoming week will be spent drafting a paper (and reading dozens of others), but I'm confident that I will be able to focus on the task at hand, cartoons or no, even if I do have to sign of facebook and focus on the "foreign language" of Chaucer, I mean Neuropsychopharmacology, for just a little while.

This essay refers to: Brook RH. A Physician = Emotion +Passion +Science. JAMA. 2010. 304; 2528-2529.

Grace

The first book that I've read in 2011 has gotten the year off to a beautiful start. Some background: I'm going to be reading an absurd number of short stories this year, because I am trying to work on my own craft in that (manageable while in medical school) genre. In order to make that possible, I've been amassing volumes to keep me busy, and I've picked up several collections over the last couple of weeks and months. One of these is Sherman Alexie's War Dances. I found this collection of poetry, short fiction, and difficult to classify but nonetheless stunning prose as a bargain book at the FABULOUS Tattered Cover in Denver, where I got to spend several very happy hours reading and browsing on New Years Eve while my husband took care of some of his groomsman duties. (We were in Denver for a wedding.)

Alexie won the 2010 PEN/Faulkner Award for this book, but I had literally never seen it on a shelf before. That's a tragedy, it's a fantastic collection, and people should be reading it. You should be reading it. I'm sure that your local library has a copy handy. It's moving and powerful writing, and more than once while I was reading it, I found myself having to look up and take a moment to collect myself. I almost cried on the bus this morning. It's been a long time since I've been moved to tears in a public place by a piece of fiction. If you're a reader, pick this up and give it a go, and let me know what you think.

Of course, pretty much everything that I have said so far sounds like it belongs in my reading blog. So why am I talking about it here, in my writing and medicine blog?

I'll tell you, in the final story in the collection, "Salt" a senile and lonely widow tells our narrator the story of burying her cat, and praying by his graveside. As she scatters salt over his body to speed his trip to heaven, he seems to come back to life. When she calls her doctor (not her veterinarian, but her physician) to report the miracle, he calls her vet, and they both make a house call. She is thrilled by this, "Imagine! Two doctors on a house call. That doesn't happen anymore, does it?" In response, the narrator thinks:

"It happens when two graceful men want to help a fragile and finite woman."

And that, my friends, might be the most beautiful sentence on humanism in medicine that I have ever read. It's what I hope to be. Graceful. What a beautiful word to describe the art of knowing what a fellow human needs, to tell us about the gift of going to great lengths to bring comfort beyond physical healing. The elegance of that sentence stopped me in my tracks. It simultaneously brought me near to tears and gave me hope. I imagine that I will remember reading this story for the rest of my career. I hope that I will, and that I will be able to use it as a touchstone, as a reminder. We are all fragile and finite, and grace is a beautiful thing to strive for.

Even if you don't want to read the rest of War Dances, read "Salt." It's only 17 pages, but it lays bare in that tiny span the fragility of humans, young and old. It's a powerful piece of writing, it will make you think. But maybe don't read it on the bus, because I think that it will likely also make you cry.